Health and Social Justice

In her ambitious book, Health and Social Justice, Jennifer Prah Ruger provides a valuable contribution to the theoretical literature on the right to health care. Building on Aristotle's theory of the good (pgs. 45-50) and Amartya Sen's elaboration of Aristotelian thought through a capability approach (pgs. 50 58), Ruger develops a health capability paradigm (pgs. 79 88) as a philosophical justification for a right to health.

There is much to commend the book. While the Aristotelian principle of human flourishing may be difficult to apply in other areas of social policy where conceptions of the good life can vary considerably, the principle fits very well in the realm of health policy. Ruger's central health capabilities of avoiding premature death and escaping morbidity (pgs. 4, 112-113) will resonate widely. Other implications of her paradigm also are appealing. Individual responsibility is a key element of her theory (pg. 82), and efficiency a core requirement (pgs. 95-98). Ruger presses the strengths of her approach, but wisely recognizes its limits. With a society of plural values, she does not try to provide a fully specified theory; instead, like the legal scholar Cass Sunstein, she invokes the method of incompletely theorized agreements to put her health capability paradigm into operation (pgs. 65 66). Readers will benefit from the impressive interdisciplinary nature of Ruger's analysis. The range of her work cuts easily across political philosophy, political science, economics, law, public health, and medical ethics.

Inevitably with a project this ambitious, there will be challenges, and Ruger will elicit some important ones. She eschews a right to health care that delivers a decent minimum to all for a higher, more demanding standard. For Ruger, society should be judged by how far its citizens fall short of reaching an optimal level of health, as measured by the potential level of health functioning that could be attained (pgs. 88-95). In a society that generally believes in two-tiered systems, where everyone receives a basic level of services and people are free to use their own resources to purchase a greater level of services (as with food, housing, or education), Ruger's higher standard will prove controversial, especially to those concerned about the costs of health care. (To be sure, Ruger tolerates some differences among people, but she works within a narrower range than many other scholars.

Some readers will question Ruger's decision to base her standard on an optimal average of health attainment [p. 89]. When she argues that society should bring all individuals to the optimal average [pg. 115], she effectively converts the optimal average into an optimal minimum.)

Ruger faces the same difficulty that has characterized other efforts to justify a right to health care. At some point, decisions must be made as to which medical services are covered and to what extent they are covered. Ruger offers a general list of services that includes care from hospitals and clinics, treatment by physicians and other health professionals (including mental health and substance abuse services), prescription drugs and nutritional supplements, and dental care (pgs. 184 185). However, she recognizes that more refined judgments will be required to allocate scarce financial resources among competing demands for health care services (pg. 172). And here is an area where Ruger could give more attention to political constraints.

In particular, Ruger expresses undue faith in the ability of public deliberation to resolve the tough choices that must be made among patients needing care. She proposes a joint scientific and deliberative process that is open and is based on both empirical evidence and input from the full range of stakeholders (individuals and their elected representatives, health care providers, and health care institutions). …

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